Special Needs Plans Care Coordination (SNPCC) protocols help to evaluate performance in the Centers for Medicare and Medicaid Services (CMS) Program Audit Protocol and Data Request related to SNPCC. The CMS performs its program audit activities in accordance with the SNPCC Program Audit Data Request and applies compliance standards outlined in the Program Audit Protocol and the Program Audit Process Overview document. At a minimum, CMS will evaluate cases against the criteria listed below. CMS may review factors not specifically addressed below if it is determined that there are other related SNPCC requirements not being met.
Audit Elements Tested
- Care Coordination
Inovaare compiled these tables from information contained within the CMS website and displayed the 2021 audit protocol changes in an easy-to-follow format. The red font indicates critical areas health plans need to address and the blue font indicates the actual data required. This table is available for download through the link at the bottom of the page.
Table 1: SNPE
|Enrollee First Name||50 CHAR||Enter the first name of the enrollee.|
|Enrollee Last Name||50 CHAR||Enter the last name of the enrollee.|
|Enrollee ID||11 CHAR||Enter the Medicare Beneficiary Identifier (MBI) of the enrollee. An MBI is the non-intelligent unique identifier that replaced the HICN on Medicare cards as a result of The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. The MBI contains uppercase alphabetic and numeric characters throughout the 11-digit identifier and is unique to each Medicare enrollee. This number must be submitted excluding hyphens or dashes.|
|Contract ID||5 CHAR||Enter the contract number (e.g., H1234) of the organization in which the enrollee is currently part.|
|Plan Benefit Package (PBP)||3 CHAR||Enter the PBP (e.g., 001).|
|Plan Type||5 CHAR||Enter type of SNP. Valid values are:
|Enrollment Effective Date||10 CHAR||Enter the effective date of the most current/continuous enrollment for the enrollee with the Sponsoring organization. Submit in CCYY/MM/DD format (e.g., 2020/01/01).|
|Most Recent Plan Change Effective Date||10 CHAR||Enter the date of last plan change within the continuous SNP enrollment.
Submit in CCYY/MM/DD format (e.g.,2020/01/01) For a PBP change or consolidation event the Sponsoring organization must use the post-event effect date for the enrollee.
Enter None if there were no PBP or plan consolidation events.
|Date of most recent HRA||10 CHAR||Enter the date of the enrollee’s most recently completed HRA.
Submit in CCYY/MM/DD format (e.g., 2020/01/01).
Enter None if no HRA was completed (e.g. when enrollee refused the HRA or was unable to be reached).
If only the Initial HRA has been completed this date should equal the Initial HRA date.
|Date of previous HRA||10 CHAR||Enter the date of the enrollee’s previously completed HRA.
Submit in CCYY/MM/DD format (e.g., 2020/01/01).
This is the date of the most recently completed HRA prior to the date entered in Column ID I.
Enter None if another HRA was not completed (e.g. when enrollee refused the HRA or was unable to be reached).
|Date Initial HRA (IHRA) was completed||10 CHAR||Enter the date of the enrollee’s first HRA completion (within 90 days before or after the effective date of enrollment).
HRA completion date is the date the HRA is returned completed to the Sponsoring organization by either the enrollee or the enrollee’s representative.
Submit in CCYY/MM/DD format(e.g., 2020/01/01).
Enter None if no HRA was completed within 90 days before or after the effective date of enrollment.
Enter EXC-10 if the IHRA date is greater than 10 years ago.
|Enrollee Risk Stratification Level at time of audit engagement letter||15 CHAR||Enter the enrollee risk level at time of the audit engagement letter.
Enter None if no risk stratification level has been assigned.
|Date of most recent Individualized Care Plan (ICP)||10 CHAR||Submit date in CCYY/MM/DD format
Enter None if the Sponsoring organization did not develop an ICP. If care plan is continuous, enter the date of the most recent update.
|Was an Interdisciplinary Care Team (ICT) created/identified?||3 CHAR||Enter Yes if the enrollee has an ICT assigned.
Enter No if the enrollee does not have an assigned ICT.
- Yellow: Audit Review Period
- Blue: valid values
- Red: important information to recognize
Disclaimer: The data included in these tables are transposed directly from the CMS website and have not been edited for grammar and format consistency. Inovaare distilled the content for your convenience and educational purposes; it should not be used as a substitute for health plan compliance team authorization. Due to the unique needs of health plans, the reader should consult her or his compliance officer to determine the appropriateness of the information contained herein.